1245772987 NPI number — EL PASO VASCULAR P A

Table of content: (NPI 1245772987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245772987 NPI number — EL PASO VASCULAR P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL PASO VASCULAR P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245772987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 GATEWAY BLVD W
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79925-3331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-779-1716
Provider Business Mailing Address Fax Number:
915-771-6496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4532 N MESA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-577-8346
Provider Business Practice Location Address Fax Number:
915-577-7932
Provider Enumeration Date:
11/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GOMEZ
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
915-577-8346

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  H3816 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00679D . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 030882701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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